Biopsy Markers

  • Bruno D. Fornage


This chapter discusses the various types of markers placed after a percutaneous needle biopsy of the breast or axilla, indications for their placement, and the errors and pitfalls associated with them. With the widespread adoption of ultrasound (US)-guided, stereotactically guided, and most recently magnetic resonance imaging (MRI)-guided percutaneous biopsy, breast imagers now frequently see metallic markers on mammograms. It is not unusual to find five or more biopsy markers in one breast. Although the placement of markers is well-intentioned to assist the breast imager, the presence of multiple markers in one breast has become a potential patient care issue as the breast imager must research the history of each marker: Does the marker mark the site of a benign or malignant lesion? Was this biopsy done under MRI, stereotactic, or US guidance? Has the marker migrated? Was more than one marker placed in a single lesion? It is therefore critical for the breast imager to become familiar with the currently available markers that are placed after a biopsy and with the issues that are directly related with their US visibility or lack thereof.


Biopsy markers Polylactic acid Polyglycolic acid Polyvinyl alcohol Gel Mark Ultra SenoMark UltraCor HydroMark SecurMark Ultraclip Embolization coil UltraCor Twirl Tumark U shape Tumark Vision Beacon BioMarC Migration Safety Complications Ultrasound visibility 

Supplementary material

Video 15.1

Insertion of custom-made metallic markers in a malignant tumor prior to neoadjuvant chemotherapy. VHS videotape recording shows the US-guided placement of the 15-gauge introducer followed by the deployment of one custom-made 5-mm rod inside the tumor. Because the marker lies perpendicular to the US beam and is solid metal, a strong comet-tail artifact is generated that makes the marker unmistakable. (MP4 41781 kb)

Video 15.2

Placement of a ribbon-type Ultraclip biopsy marker in a low axillary lymphomatous node. The bevel of the 17-gauge needle is facing up, and the exit of the marker and its proper location are easily documented. (See also Fig. 15.7.) (MOV 2449 kb)

Video 15.3

Placement of a wing-type Ultraclip marker in a 6-mm carcinoma. (See also Fig. 15.8.) (MOV 4347 kb)

Video 15.4

Placement of a coil-type Ultraclip marker in a markedly hypoechoic invasive ductal carcinoma. Note the good visibility of the small standard (non-enhanced) metallic clip and the distinctive comet-tail artifact that unequivocally identifies the metallic foreign body. (See also Fig. 15.9.) (MOV 3336 kb)

Video 15.5

Post-biopsy deployment of a coil-type US-enhanced Ultraclip marker in a malignant tumor in the 4 o’clock position of the right breast. The metallic coil marker does not appear as a typical metallic foreign body because it is embedded in the long, mildly echogenic polyvinyl alcohol polymer pellet. Compare the echogenicity of the pellet-embedded marker with that of the needle. (See also Fig. 15.14.) (MP4 7439 kb)

Video 15.6

Post-biopsy deployment of a coil-type US-enhanced Ultraclip marker in an intracystic papilloma. The polyvinyl alcohol polymer pellet is seen, not the actual metallic marker. (See also Fig. 15.15.) (MOV 2660 kb)

Video 15.7

VHS videotape recording of the deployment of an embolization coil in a malignant tumor. In this case, the coil advances into the tumor in the downward direction. In fact, the exit direction of many markers in the target lesion is often random and unpredictable. (MP4 12970 kb)

Video 15.8

Deployment of a U-shaped Tumark marker. The marker exits the needle through the bevel in the upward facing direction in this case. However, the marker may exit the needle in various directions. (MOV 4541 kb)

Video 15.9

Good detectability of a U-shaped Tumark marker thanks to its high reflectivity and specific curved shape. (See also Fig. 15.21.) (MP4 9606 kb)

Video 15.10

Real-time examination shows the body and two horns of a U-shaped Tumark marker deployed in an axillary lymph node metastasis. (MP4 7462 kb)

Video 15.11

Good response to neoadjuvant chemotherapy of a metastatic axillary lymph node. The characteristic twirled body and both horns of a Tumark marker are easily identified in the residual node. (MP4 4345 kb)

Video 15.12

Complete response to neoadjuvant chemotherapy of a metastatic axillary lymph node. The node has resumed a quasi-normal sonographic appearance. The twirled metallic Tumark marker (arrow) can be identified in the cortex of the node. (MOV 12192 kb)

Video 15.13

Video of a residual HydroMark marker after complete response of a cancer to neoadjuvant chemotherapy. The three whorls of the central coil (arrow) are clearly visible. (See also Fig. 15.34.) (MOV 9203 kb)

Video 15.14

HydroMark marker placed outside of a cancer mimicking intraductal extension toward the nipple. Video shows the rectangular shape of the marker’s gel cylinder on longitudinal views and then its circular section on transverse views. (See also Fig. 15.37.) (MOV 28528 kb)

Video 15.15

Expulsion of a U-shaped Tumark marker out of the needle. The marker regains its curved shape inside the tumor as soon as it exits the needle. (See also Fig. 15.38.) (MP4 4934 kb)

Video 15.16

Expulsion of a U-shaped Tumark marker anterior and superior to the needle’s bevel. The marker regains its shape inside the tumor as soon as it exits the needle. (See also Fig. 15.39.) (MP4 16273 kb)

Video 15.17

Rotation of the needle of a marker applicator to help identify the bevel and place the bevel in the optimal position (facing upward) to monitor the expulsion of the biopsy marker in real time. (MOV 2629 kb)

Video 15.18

Pitfall associated with some markers, which may remain “hooked” by the bevel of the needle and dragged backward during the withdrawal of the needle. In this case, a non–US-enhanced coil-type Ultraclip’s hook caught the edge of the needle’s bevel and remained attached to the bevel while the operator began to withdraw the needle (first arrow). As soon as this was noticed, the operator pushed the marker back in the center of the tumor and briefly rotated the needle clockwise and counterclockwise (second arrow), which freed the marker from the needle. It is important to monitor not only the placement of the needle but also the actual delivery of the marker in real time to detect such an event and apply the fix immediately. (MOV 20898 kb)

Video 15.19a

Twinkling artifact associated with a U-shaped Tumark marker in a tumor containing numerous malignant microcalcifications. Power Doppler US examination of the tumor shows the artifact associated with the marker but also the twinkling of the surrounding microcalcifications. A pitfall would be to misinterpret those signals as evidence of tumor-associated vascularity. (See also Fig. 15.50.) (This video appears also in Chap.  2 as Video  2.8A and  2.8B) (MOV 3416 kb)

Video 15.19b

Twinkling artifact associated with a U-shaped Tumark marker in a tumor containing numerous malignant microcalcifications. Color Doppler US shows the true twinkling artifact with the typical alternating high-velocity (yellow and green) signals. (See also Fig. 15.50.) (This video appears also in Chap.  2 as Video  2.8A and  2.8B) (MOV 1623 kb)

Video 15.20a

Twinkling artifact on color Doppler US (CDUS) helps identify a metallic marker but should not be mistaken for a vessel on power Doppler US (PDUS). PDUS examination of a residual tumor after neoadjuvant chemotherapy shows a vertical Doppler signal suggesting the presence of a vessel. (See also Fig. 15.51.) (MOV 1712 kb)

Video 15.20b

Twinkling artifact on color Doppler US (CDUS) helps identify a metallic marker but should not be mistaken for a vessel on power Doppler US (PDUS). Switching back to CDUS shows the typical twinkling artifact with alternating high-velocity (green and yellow) Doppler signals representing reverberations inside the metallic biopsy marker. (See also Fig. 15.51.) (MOV 2254 kb)

Video 15.21

Preoperative real-time identification of one of two residual subcutaneous U-shaped Tumark markers that had been placed to bracket a local recurrence of breast cancer. The tumor has completely responded to chemotherapy, leaving the Tumark marker isolated in the subcutaneous fat. The marker is identified through the twirled curved shape of its main body and its two horns (yellow circle). (See also Fig. 15.54.) (MOV 21272 kb)


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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Bruno D. Fornage
    • 1
  1. 1.The University of Texas MD Anderson Cancer CenterHoustonUSA

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